BACKGROUND: In 2023, an estimated 36 million pregnancies occurred in malaria endemic sub-Saharan Africa, but only 44% received the WHO recommended ≥ 3 doses of intermittent preventive treatment (IPTp3). Group Antenatal Care (G-ANC) is a service delivery model associated with higher quality of and greater retention in ANC, in which pregnant women are enrolled into groups at their first ANC visit and subsequent care is provided in groups. A cluster-randomized controlled trial was conducted in Atlantique Department, Benin, to assess whether G-ANC improved ANC retention and IPTp3 uptake at community level. METHODS: Forty purposively selected health facilities (HF) were randomized 1:1 to control (individual ANC) or G-ANC. Cross-sectional household surveys to measure uptake of ANC and IPTp were conducted in each HF catchment area before and after implementation among randomly selected women who had given birth in the previous 12 months. Changes in coverage were assessed using a difference-in-difference approach, adjusting for HF clustering. RESULTS: At baseline (N = 1259), coverage of at least 4 ANC visits (ANC4) and IPTp3 was 52.8% and 48.0%, respectively, in the intervention catchment, and 44.9% and 49.4% in the control catchment. Coverage of ANC4 improved in both arms by endline (N = 1280), to 56.7% in the intervention and 46.1% in the control, but the difference in the increase was not significant between arms (p = 0.51). Coverage of IPTp3 increased non-significantly (p = 0.26), to 53.2% (intervention) and 49.7% (control). Overall, only 140 (10.6%) surveyed women reported participating in G-ANC. Participation improved coverage of both ANC4 (65.0% vs 50.5%, p = 0.002; odds ratio (OR) 1.9, 95% CI 1.4-2.5) and IPTp3 (64.0 vs 50.6%, p = 0.004; OR = 1.8, 95% CI 1.2-2.6). CONCLUSIONS: G-ANC increased ANC attendance and IPTp3 uptake among women who participated, but participation was limited. Understanding and addressing the barriers to participation is critical if G-ANC is to be used more widely to increase IPTp coverage. TRIAL REGISTRATION: PACTR202405487752509.

INTRODUCTION: Antenatal care (ANC) interventions improve maternal and neonatal outcomes. However, access to ANC may be inequitable due to sociocultural, monetary and time factors. Examining drivers of ANC disparities may identify those amenable to policy change. METHODS: We conducted an ANC services equity analysis in selected public facilities in Geita, Tanzania, where most services are free to the end-user, and Atlantique, Benin, where every visit incurs user fees. Data on total ANC contacts, quality of care (QoC) indicators and wait times were collected from representative household surveys in the catchment of 40 clinics per country and were analysed by education and wealth. We used indices of inequality, concentration indices and Oaxaca-Blinder decompositions to determine the distribution, direction and magnitude of inequalities and their contributing factors. We assessed out-of-pocket expenses and the benefit incidence of government funding. RESULTS: ANC clients in both countries received less than the recommended minimum ANC contacts: 3.41 (95% CI 3.36 to 3.41) in Atlantique and 3.33 (95% CI 3.27 to 3.39) in Geita. Wealthier individuals had more ANC contacts than poorer ones at every education level in both countries; the wealthiest and most educated had two visits more than the poorest, least educated. In Atlantique, ANC attendees receive similar QoC regardless of socioeconomic status. In Geita, there are wide disparities in QoC received by education or wealth. In Atlantique, out-of-pocket expenses for the lowest wealth quintile are 2.7% of annual income compared with 0.8% for the highest, with user fees being the primary expense. In Geita, the values are 3.1% and 0.5%, respectively; transportation is the main expense. CONCLUSIONS: Inequalities in total ANC visits favouring wealthier, more educated individuals were apparent in both countries. In Atlantique, reduction of user-fees could improve ANC access. In Geita, training and equipping healthcare staff could improve QoC. Community health services could mitigate access barriers.